Provider Demographics
NPI:1417434150
Name:MCKENZIE, SHANNON L
Entity Type:Individual
Prefix:MR
First Name:SHANNON
Middle Name:L
Last Name:MCKENZIE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3913 LYNN DR
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-5745
Mailing Address - Country:US
Mailing Address - Phone:907-336-0080
Mailing Address - Fax:
Practice Address - Street 1:3913 LYNN DR
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-5745
Practice Address - Country:US
Practice Address - Phone:907-336-0080
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-25
Last Update Date:2018-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1063221251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health